Acute diseases and injuries of the scrotum and penis in children: clinical guidelines

List of Abbreviations

ABT – antibiotic therapy

ASAT – antisperm antibodies

EAU – European Association of Urology

MRI – magnetic resonance imaging

CBC – complete blood count

UA – urinalysis

ATD – acute testicular diseases

РКИ – randomized controlled trial

GR – grade of recommendation

LE – level of evidence

US – ultrasound examination

CDU – color duplex ultrasonography

CDI – color Doppler imaging

Terms and Definitions

Balanoposthitis – inflammation of the glans penis (balanitis) and prepuce (posthitis)

Testicular dislocation – displacement of one or both testes due to trauma beneath the abdominal skin, into the inguinal canal, perineum, or thigh

Testicular appendage (appendix testis, Morgagni's hydatid) – a small vestigial structure representing a remnant of the cranial Müllerian duct, located on the upper pole of the testis

Appendix of the epididymis – a small vestigial structure originating from the Wolffian duct and located on the head of the epididymis

Intermittent testicular torsion – episodes of testicular twisting and spontaneous detorsion

Intravaginal testicular torsion – torsion of the spermatic cord within the cavity of the tunica vaginalis

Short frenulum of the prepuce – reduced length of the preputial frenulum and/or decreased elasticity thereof

Manual detorsion – a manipulation used in testicular torsion involving manual rotation of the testis in the direction opposite to the twist

Paraphimosis – entrapment of the glans penis resulting from constriction by the preputial ring, leading to circulatory impairment

Testicular torsion – twisting of the spermatic cord leading to partial or complete blood flow obstruction and testicular ischemia

Appendiceal torsion – torsion of the stalk of a vestigial structure (Morgagni's hydatid), leading to secondary inflammatory changes in the scrotal contents

Testicular torsion with spontaneous detorsion – torsion that resolves spontaneously without medical interventions

Priapism – a pathological hemodynamic state characterized by a prolonged erection lasting more than 4 hours and unrelated to sexual stimulation

Recurrent testicular torsion – testicular torsion that recurs following surgical treatment

Testicular rupture – traumatic injury to the tunica albuginea and testicular parenchyma

Epididymal rupture – traumatic injury to the capsule and parenchyma of the epididymis

Blue dot sign – visualization of a twisted, necrotic hydatid transilluminating through the scrotal skin

Whirlpool sign – spiral appearance of the spermatic cord in testicular torsion on ultrasound and CDI

Trauma – an injury defined as a disruption of the anatomical integrity or physiological functions of human body tissues and organs resulting from external factors (mechanical, thermal, chemical, etc.)

Traumatic penile amputation – complete detachment of the penis from the body as a result of trauma

Phimosis – narrowing of the prepuce preventing exposure of the glans penis

Circumcision – surgical removal of the prepuce

Extravaginal testicular torsion – torsion of the spermatic cord outside the cavity of the tunica vaginalis, involving all layers together

Bell-clapper deformity – an anatomical variant where the tunica vaginalis surrounds the spermatic cord, predisposing to intravaginal testicular torsion

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Acute testicular diseases (ATD) – a collective term encompassing several acute scrotal conditions presenting with similar clinical manifestations: pain, edema, and varying degrees of hyperemia [1-9]. In Russian literature and clinical practice, the terms "acute scrotum syndrome", "acute scrotal edema syndrome", and "acute edematous and hyperemic scrotum syndrome" are also used [1-8], while English-language literature uses "acute scrotum" and "acute scrotal disease" [5, 9-11].

The primary conditions included under ATD are torsion of the testicular appendage and torsion of the epididymal appendage; testicular torsion; and acute inflammatory diseases of the scrotum (orchiepididymitis, epididymitis).

Appendiceal torsion (appendix testis torsion, torsion of the testicular appendix) – torsion of the stalk of vestigial structures in the region of the upper testicular pole or epididymis. The literature also uses the terms: appendiceal necrosis, acute appendiceal lesion, pathology of Morgagni's hydatid, testicular/epididymal appendage. Appendiceal torsion is the most frequent pathology within the structure of ATD in children, accounting for 62–84% [1-9, 11-15].

Testicular torsion (spermatic cord torsion, testicular torsion, spermatic cord torsion) – twisting of the spermatic cord leading to partial or complete blood flow obstruction and testicular ischemia. Testicular torsion is the most severe condition associated with ischemia and the risk of testicular necrosis, accounting for 11–23% of ATD cases [1-15, 18].

Acute inflammatory diseases of the scrotum – nonspecific epididymitis, orchitis, and epididymo-orchitis occur with a frequency of 12–18% [1-15, 18]. Inflammatory changes of the epididymis are most common, with the testis being involved in the pathological process secondarily. The inflammatory process can be either infectious (bacterial) or aseptic in nature.

Rare forms of ATD include allergic scrotal edema, parasitic diseases, testicular tumors, thrombosis of the spermatic cord vessels, and Fournier's gangrene [1, 4, 19].

Among acute penile conditions, balanoposthitis and paraphimosis are the most common in children. Phimosis cannot be classified as an acute condition; however, it may contribute to the development of balanoposthitis and lead to acute urinary retention.

Balanoposthitis is an inflammatory condition characterized by inflammation of the glans penis (balanitis) and the prepuce (posthitis).

Phimosis – narrowing of the prepuce preventing exposure of the glans penis.

Paraphimosis – entrapment of the glans penis resulting from constriction by the preputial ring, leading to circulatory impairment.

Priapism – a pathological hemodynamic state characterized by a prolonged erection lasting more than four hours and unrelated to sexual stimulation [16].

Injuries of the scrotum and penis – disruption of the anatomical integrity and/or physiological functions of the scrotal and penile organs resulting from external factors (mechanical, thermal, chemical, etc.). Injuries can be either closed (blunt) or open (wounds) [1-8].

Scrotal hematoma – hemorrhage into the scrotal wall.

Testicular contusion is an organ injury without structural disruption.

Testicular rupture is damage to the tunica albuginea and testicular parenchyma.

Rupture of the epididymis is damage to the capsule and parenchyma of the epididymis.

Post-traumatic epididymitis is aseptic inflammation of the epididymis following trauma.

Testicular dislocation or dislocating injury is the displacement of one or both testes into the inguinal canal, subcutaneous tissue of the abdomen, perineum, or thigh as a result of trauma.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Testicular torsion. Against the background of existing congenital anomalies of testicular fixation, a sharp contraction of the cremaster muscle, which pulls the testis upward, causes the testis to twist along the axis of the spermatic cord. Further reflex involuntary contractions of the muscle lead to an increased degree of torsion, sometimes up to 2–3 full rotations. This causes vascular compression and testicular ischemia; if timely assistance is not provided within 4–8 hours, given the sensitivity of testicular tissue, irreversible necrotic changes develop [1-9, 11-14]. In incomplete torsion, testicular viability may be preserved even with a longer duration of the disease.

Hydatid torsion. Circulatory impairment of the hydatid occurs as a result of the twisting of its stalk due to inertial forces generated during testicular movement. When the cremaster muscle contracts, the testis may perform a short rotational movement around its axis. The hydatid continues to rotate by inertia, which contributes to its torsion. As a result of the twisting of the stalk, hemorrhagic infarction of the hydatid develops—diffuse hemorrhage into the stroma and organ necrosis. Infarction of the hydatid can also occur without twisting of the stalk, as a result of thrombosis of the hydatid stalk vein, due to kinking and rotation caused by high organ mobility [1-9].

Acute inflammatory diseases of the scrotum. Causes of inflammation include bacterial, abacterial, and traumatic factors. Inflammatory changes in the epididymis are most frequently observed, with the testis being involved in the pathological process secondarily (epididymo-orchitis) [1-10, 86, 88]. Isolated orchitis is a rare disease. It is usually caused by a hematogenous viral infection. Mumps is the most common cause of viral orchitis, but infectious mononucleosis has also been described as an etiological factor [5]. In prepubertal boys, the etiology of epididymitis is usually unknown, as the infectious agent is identified in only 25% of cases. Urine culture is usually sterile, and unlike in older boys, the incidence of sexually transmitted infections is very low [5]. Congenital anomalies of the urogenital tract can lead to urodynamic disorders and the development of epididymitis. Reflux of sterile urine through the vas deferens into the epididymis leads to an inflammatory process. Bacterial flora plays a role in the etiology of bacterial epididymo-orchitis, most commonly represented by Escherichia coli, Staphylococcus, Streptococcus, and less frequently by Proteus, Enterococcus, and Pseudomonas aeruginosa. Four pathways of infection penetration into the epididymis and testis have been described: hematogenous, lymphogenous, secretory, and canalicular (ascending) [4, 5]. The canalicular pathway of infection is supported by the fact that epididymitis almost never occurs in systemic infectious diseases. In epididymo-orchitis, the epididymis is primarily affected, with destructive changes most frequently found in the tail of the epididymis. Antiperistaltic contractions and increased hydrostatic pressure in the prostatic urethra and vas deferens contribute to the spread of infection. Comparative analysis of microorganisms isolated from various media (urethral swabs, midstream urine, epididymal and testicular biopsies) confirmed their identity [98]. In hematogenous spread of infection, the testis is primarily affected, which is possible in septicopyemia or viremia during infectious diseases (mumps, pneumonia, typhoid fever, scarlet fever, chickenpox, etc.). Bacterial epididymo-orchitis may be complicated by testicular abscess or necrosis [5, 71].

A significant number of cases of epididymitis are caused by trauma to the epididymis and testis. At the same time, the isolation of pathogenic microflora in these cases is due to the development of secondary infection against the background of primary aseptic inflammation caused by microcirculation disorders in the testicular and epididymal parenchyma [4].

Recent studies indicate a high incidence of functional urodynamic disorders in acute epididymitis [5]. Some authors consider incomplete (functionally conditioned) bladder emptying to be the primary cause of acute epididymitis.

Allergic edema of the scrotum most commonly occurs in children with an unfavorable allergic history [4, 20-22]. However, taking a history usually fails to establish the etiological factor, which is why the term idiopathic edema is frequently used.

Parasitic diseases of the scrotal organs. Dirofilariasis is a disease caused by parasitization of nematodes of the genus Dirofilaria in the human body. Infection occurs vector-borne via the bite of blood-sucking insects carrying dirofilariasis larvae. Domestic dogs and cats, less often wild animals, are the usual source of infection for mosquitoes. Humans are accidental dead-end hosts for Dirofilaria worms because females do not reach sexual maturity in the human body. Most larvae perish upon entering the human body. Humans are not a source of infection. In the vast majority of cases, a single specimen—an immature female—is found in the body. The clinical incubation period depends on the body's reactivity and the parasite's growth rate, ranging from one month to several years—most commonly around 6 months, by which time an inflammatory infiltrate has formed. As a rule, the helminth is located within a connective tissue capsule containing seropurulent exudate, protein, eosinophilic, and neutrophilic cells [4, 19, 23, 24].

Fournier's gangrene (fulminant gangrene of the scrotum, Fournier's gangrene, Fournier's phlegmon) is an acute infectious necrotizing fasciitis primarily affecting the external genitalia and perineum. Fournier's gangrene has two main characteristics: a sudden onset without an apparent triggering factor and a fulminant course. Publications regarding Fournier's disease in pediatric age are sporadic and descriptive [4, 19, 26-28]. Over recent years, a 2.2- to 6.4-fold increase in incidence has been noted [19, 26-29].

Thrombosis of the spermatic cord vessels is a rare condition requiring differential diagnosis with testicular torsion; in the neonatal period, it occurs against the background of neonatal polycythemia [4].

Segmental testicular infarction is extremely rare in pediatric patients [4, 19, 31-32].

Emergencies in testicular neoplasms.

Neoplasms of the scrotal organs (primarily testicular) are characterized by the presence of a palpable mass, gradual growth, pain syndrome only when the mass is very large, and, in malignant courses, clinical manifestations caused by metastasis. Nevertheless, in rare cases, acute pain may occur in a patient with a testicular mass, mimicking an "acute scrotum syndrome" [4, 19, 30].

Balanoposthitis. The pathogenesis of balanoposthitis involves the development of an inflammatory process with edema, hyperemia, exudation, formation of erosions and ulcers, and sometimes narrowing of the foreskin (phimosis) or entrapment of the glans penis (paraphimosis) [53, 56, 139]. The main causes of balanoposthitis in children include:

• infectious: bacterial (Streptococcus, Staphylococcus, Escherichia coli, etc.), viral (herpes, papillomavirus), fungal (Candida),

• allergic: contact dermatitis, reaction to irritants (soap, urine, etc.),

• traumatic: scratching, manipulations,

• xerotic obliterans balanitis (balanoposthitis) – a chronic sclerosing inflammatory disease of unclear etiology.

Priapism. The pathogenesis of priapism is associated with impaired erection mechanisms and blood outflow from the penis [16, 56-59]. Ischemic priapism involves impaired venous outflow, while non-ischemic priapism involves increased arterial inflow. The main causes of priapism in children include:

• idiopathic (unspecified) priapism,

• sickle cell anemia,

• penile trauma,

• pelvic tumors,

• medications (psychotropics, antidepressants, antineoplastics, etc.).

Paraphimosis is a complication of both congenital (physiological) and acquired phimosis. It occurs when a narrowed foreskin is forcibly retracted behind the glans penis to expose it [41]. It most commonly occurs in children with congenital phimosis and during medical manipulations such as urinary catheterization.

The pathogenesis of paraphimosis is associated with edema and compression by the incarcerated prepucial skin, leading to impaired venous return and arterial stasis in the glans penis. This, in turn, exacerbates the edema and incarceration, which can lead to necrosis of the foreskin [5] and the glans penis [33, 40-42, 53].

Scrotal trauma. In adults, cross-country cycling and motorcycling (especially on gasoline-powered motorcycles), rugby, football, and hockey are considered the main causes of blunt testicular trauma [5]. Penetrating injuries in men can be caused by gunshot wounds (75.8%) and generally require surgical treatment [4, 5, 48-49, 55-56]. Severe testicular injury is accompanied by rupture of the tunica albuginea and herniation of a portion of the parenchyma. Disruption of the integrity of the tunica albuginea occurs from a direct impact under conditions where the testis is fixed between the impacting object and the pelvic bones. The rupture occurs along the course of the elastic fibers and is usually transverse [1, 4]. The main plexuses of venous and lymphatic vessels located on the lateral surface of the testis are damaged. Testicular trauma results in hemorrhage into the connective tissue septa and parenchyma. Impairment of lymphatic drainage through the tunica albuginea leads to functional overload and its dynamic blockade. Edema increases within the testis and its membranes, exacerbating the protrusion of the parenchyma through the existing defect of the tunica albuginea. The most severe degree is considered to be complete pulping of the testis or its avulsion from the spermatic cord [1, 4, 48-49].

Open injuries of the scrotum and its contents can present as lacerations, incisions, stab wounds, animal bites, and shrapnel wounds. They may be accompanied by injuries to the penis and testis. In wounds penetrating into the serous cavity of the testis, scrotal organs may prolapse outward through the wound [1, 4]. Open injuries result from falling onto sharp objects, while rupture of the tunica albuginea does not occur due to the protective action of the cremasteric reflex.

Penile injuries in children can occur as a result of active play and sports. Traffic accidents can also lead to genital trauma [33]. Iatrogenic injuries result from medical procedures, most commonly circumcision. Dog bites are the most common bite injury to the penis in children [34-35]. Penile burns are rarely isolated and usually involve multiple body areas [35]. Electrical injuries, such as electric shocks, can cause significant damage to penile tissues. In addition, cases of penile entrapment by hair in children [36], zipper entrapment of the penis [37], and toilet seat injuries [38] have been described. As a result of trauma, circulatory disorders, infectious complications, urethral strictures, deformity, and impaired penile function may develop.

Testicular dislocation, or dislocating injury, is the displacement of one or both testes as a result of trauma into the inguinal canal, subcutaneous tissue of the abdomen, perineum, or thigh [4, 5, 50-52]. Testicular displacement occurs under the influence of two factors: scrotal trauma and a sharp protective contraction of the cremaster muscle. As a rule, the testis does not spontaneously descend back into the scrotum, which is explained by the features of its location upon displacement, as well as edema of the testis and surrounding tissues. Testicular dislocation is often combined with contusion and sometimes with rupture of the tunica albuginea [4, 50-52].

1.3 Epidemiology of the Disease or Condition

Testicular torsion occurs most frequently in the neonatal period and puberty, whereas torsion of the appendix testis occurs over a broader age range [1-9, 42-43]. In the perinatal period, spermatic cord torsion most often develops before birth, with bilateral involvement observed in 11–21% of cases [43]. In most cases, torsion occurs extravaginally, in contrast to intravaginal torsion typical of puberty [1-9, 13].

Torsion of the appendix testis. The highest incidence of the disease is typical for ages 7–11 years, with a peak at 8–9 years or slightly older at 7–12 years [1-9, 42-45]. The proportion of children under 3 years of age is no more than 4% [1-9, 15, 47]. Casuistic cases have also been described in newborns. D.W. Chiles first described a case of appendix testis torsion in newborns, presenting a description of a 16-hour-old patient (presumably the torsion occurred antenatally) [44]. Cases of bilateral torsion of the appendix testis have been noted [45].

Acute epididymitis is one of the most common diseases of the reproductive system, accounting for 12% to 18% of all patients with acute scrotal pathology [1-9, 46], and occurs in all pediatric age groups.

Rare forms of "acute scrotum" syndrome. A number of nosological forms manifesting as acute scrotal pathology are rare in clinical practice, accounting for a total of no more than 1–2% of the syndrome's structure [1, 4, 19]. The incidence of each of these accounts for a fraction of a percent within the structure of the "acute scrotum" syndrome; nevertheless, these nosological entities have their own characteristic features and patterns.

Allergic scrotal edema accounts for less than 0.5% of acute scrotal diseases. The condition is most characteristic of early childhood: children under 1 year of age account for 25% of the overall structure of allergic scrotal edema, 1–3 years for 55%, 3–7 years for 15%, and over 7 years for 5% [1-9, 19-22]. According to the European Association of Urology (EAU), it occurs most frequently in boys under 10 years of age, typically between 4 and 7 years [5].

Parasitic diseases of the scrotal organs. Dirofilariasis is more common in adults, peaking at 40–49 years of age; an exception is Sri Lanka, where the maximum incidence is noted in children under 9 years of age, and the minimum age of detection is 4 months, which is due to local customs (children going naked). The spread of the disease covers the territory of 37 states. In Russia, it occurs at various ages, with cases registered at ages 3–75 years with an indistinct peak at 30–39 years. In the period 1956–1995 in Russia and the CIS countries, D. repens infestation was detected in 91 people, whereas for the period 1996–2001 in Russia alone, 152 cases were already registered; in 2011, 84 cases were registered in 31 constituent entities of the Russian Federation, and in 2012, 143 cases. It is predominantly found in southern regions, but cases of infection in central Russia and the north are not uncommon [23-24].

Fournier's gangrene - is a rare disease in urological practice, being casuistic in childhood. Prior to 1960, only 25 cases had been described in domestic literature; by 1992, their number had already reached 500, indicating better awareness among specialists. A total of 3,297 cases of the disease were reported between 1950 and 2007. In childhood, 63 cases of the disease have been described, with 43 (65%) occurring in children under three years of age. Cases in newborns have also been described [4, 19, 25-28].

Scrotal emergencies can occur in varicocele (orchialgia, thrombosis/thrombophlebitis of the testicular veins, rupture of the testicular veins), spermatocele (torsion of the spermatocele, rupture of the spermatocele, suppuration of the spermatocele); emergencies are also possible in funiculocele and hydrocele [4, 19].

Scrotal emphysema (pneumoscrotum). It is customary to distinguish primary pneumoscrotum (the result of direct damage to the scrotal wall and/or its contents) and secondary pneumoscrotum (diffusion of gas from any other anatomical region). The latter is most often iatrogenic [4, 19].

Emergencies in urogenital tuberculosis in children. In Russia, no more than 100 pediatric patients with urogenital tuberculosis are detected annually, of whom no more than 10% have genital tuberculosis [4, 19]. The occurrence of urgent situations in scrotal tuberculosis in children is very rare and arises upon the addition of nonspecific inflammation or (much less frequently) destruction of the tuberculous focus. The greatest attention should be paid to acute epididymitis with a subacute or protracted course.

Balanoposthitis is one of the most common diseases in boys. According to WHO data, balanoposthitis occurs in approximately 4–11% of boys under 15 years of age. In 75% of cases, balanoposthitis occurs in boys under 10 years of age, leading to acute urinary retention in 16% of children. Balanoposthitis develops in 6% of uncircumcised boys [53, 148].

Precise statistical data on the prevalence of priapism in children are lacking. According to various estimates, priapism occurs in 1.5–2.9 per 100,000 children per year. Priapism most frequently develops in boys aged 5–10 years [16].

According to various literature sources, the incidence of paraphimosis in children varies from 0.1% to 0.4% of all андрологических заболеваний [andrological diseases]. Paraphimosis is more common in older boys and adolescents [40-41].

Scrotal injuries. Within the structure of the acute scrotum syndrome, the incidence of traumatic injuries is low, although the figures cited by authors vary [1-9, 14, 48, 55, 64-65]. In recent years, there has been a tendency towards an increase in their number. For instance, according to I. P. Krapivina et al. (2011), when comparing the periods 1987–1997 and 1998–2008, an increase in the specific weight of scrotal injuries within the structure of «acute scrotum syndrome» from 5.3 to 6.8% was noted [47]. The nature and severity of trauma are changing. Thus, H.L. Sang (2017), analyzing a 30-year period (1985–2015), stated changes in the etiological factor of injuries towards a decrease in the number of criminal injuries and an increase in the number of sports and domestic injuries; he also noted a decrease in injury severity [48]. The causes of injury were sports competitions in 47% of patients [63], falls in 38.2%, and motor vehicle accidents in 24.4%.

Bilateral scrotal injury is rare, accounting for 1–8% of blunt trauma cases, but in open injuries, it can rise to up to 30% [47-49]. According to M. Monga (1996), the incidence of bilateral injuries is no more than 1% [49]. Traumatic dislocation of the testis is rare. According to the EAU, across all ages, testicular dislocation is most commonly observed after road traffic accidents [50-52], with bilateral displacement described in 25% of cases [51].

Precise statistics on the prevalence of penile injuries in children are lacking [130-133, 135]. According to WHO data, more than 1 million cases of urogenital system injuries in children are registered worldwide annually, of which 10–15% are penile injuries. Penile injuries most frequently occur in children aged 3–12 years, which is associated with their increased physical activity. Most published data concern penile injuries arising during circumcision (bleeding, skin damage, injury to the external urethral meatus) up to partial or complete amputation of the glans penis [38, 136, 138].

1.4 Features of Coding the Disease or Condition

N44 Testicular torsion

N49.2 Inflammatory diseases of scrotum

N49.8 Inflammatory diseases of other specified male genital organs

N49.9 Inflammatory disease of male genital organ, unspecified

N45.0 Orchitis, epididymitis and epididymo-orchitis with abscess

N45.9 Orchitis, epididymitis and epididymo-orchitis without abscess

N51.1 Disorders of testis and epididymis in diseases classified elsewhere

N51.2 Balanitis in diseases classified elsewhere

S30.2 Contusion of external genitalia

S31.2 Open wound of penis

S31.3 Open wound of scrotum and testes

S31.5 Open wound of other and unspecified external genital organs

N47 Redundant prepuce, phimosis and paraphimosis

N48.1 Balanoposthitis

N48.3 Priapism

N48.6 Balanitis

1.5 Classification of the disease or condition

Testicular torsion

By form:

• extravaginal

• intravaginal

By clinical course:

• typical

• atypical

  ▪ testicular torsion with spontaneous detorsion

  ▪ intermittent testicular torsion

  ▪ recurrent testicular torsion (after fixation)

  ▪ testicular torsion in the inguinal canal (with cryptorchidism)

  ▪ torsion of an abdominally located testis

  ▪ bilateral testicular torsion (synchronous or asynchronous)

  ▪ torsion of an appendix testis (hydatid)

By degree:

• incomplete (up to 360°)

• complete:

  ▪ grade 1 from 360° to 450°

  ▪ grade 2 from 450° to 720°

  ▪ grade 3 - 720° and more [4]

Complications: testicular necrosis, testicular abscess

Torsion of the hydatid of Morgagni. Currently, there is no universally accepted classification for hydatid pathology. Attempts have been made to categorize the disease by the mechanism of development: torsion and thrombosis of the hydatid [7], but this has not found widespread clinical application due to the absence of tactical differences in management. There is a similar term - transformation of the hydatid, more commonly used by ultrasound diagnostics specialists [4]. Attempts at systematization based on the site of hydatid attachment have not gained widespread use, due to the lack of influence of the hydatid fixation point on the nature of the induced changes and management tactics.

In clinical practice, the course of the disease is of the utmost importance, as it differs clinically and echographically [1, 4]. This gradation appears to be the most rational of the existing ones, since the state of the scrotal organs and the nature of changes caused by the pathological process in the hydatid can be determined preoperatively clinically and using imaging methods, allowing the determination of further management tactics (conservative or surgical) [1, 4, 157].

By the nature of the course:

• complicated

• uncomplicated

Epididymo-orchitis, orchitis, and epididymitis. All existing classifications pertain to adults and are poorly adapted for children due to different etiopathogenetic mechanisms [71, 86, 88, 90-92, 122]. Thus, granulomatous and congestive epididymitis do not occur in pediatric practice [4].

We have not found classifications of acute epididymitis in children in domestic literature. Some foreign authors subdivide epididymitis in children by severity, distinguishing two forms - severe, requiring surgery, and mild, amenable to conservative therapy [46, 54, 71].

Scrotal injuries. Of greatest importance in clinical practice is the systematization of injuries according to the nature of the injury and the severity of damage [4, 5].

By the nature of the injury:

• Open (wounds): lacerated, contused, puncture, incised, gunshot, etc.

  ▪ penetrating

  ▪ non-penetrating

• Closed (blunt)

In 1987, the American Association for the Surgery of Trauma (AAST) developed the Organ Injury Scale (OIS) for scrotal trauma, and in 1995 an improved version of the scale was presented, used in almost all guidelines (Table 1).

Table 1. Classification of scrotal injuries (AAST)

In recent years, this grading system has become popular among Russian urologists and has been widely adopted for practical use in both adults and children, as it most thoroughly and clearly reflects the necessary assessment criteria and allows for the unification and standardization of management tactics.

Penile injuries

By the nature of the injury:

• Open (wounds, rupture of the frenulum of the penis, penile amputation)

• Closed (contusions, penile fracture, penile entrapment)

Penile fracture in children is rare, but may occur with sharp bending of the penis. The thickness of the tunica albuginea in the flaccid state is about 2 mm, and during erection it decreases to 0.25–0.5 mm, making it more vulnerable to traumatic injury [129-133].

By severity:

• Mild (contusion, abrasion, superficial wound)

• Moderate (deep wound, partial rupture)

• Severe (complete amputation, severe destruction)

Balanoposthitis

By etiology:

• infectious

• allergic

• traumatic

• xerotic obliterans balanitis (balanoposthitis)

By clinical course:

• acute

• chronic

Priapism [57]

By etiology:

• idiopathic

• secondary (associated with an underlying condition)

By clinical course:

• low-flow (ischemic and veno-occlusive)

• intermittent (intermittent and recurrent ischemic)

• high-flow (non-ischemic and arterial)

Low-flow priapism is the most common type observed in children [16, 58]. High-flow priapism is usually caused by a post-traumatic arteriocavernous fistula (from penile, perineal, or pelvic trauma) and typically manifests a few days after the injury [59].

Paraphimosis

By severity:

• mild degree (reversible changes, edema of the glans penis)

• moderate degree (circulatory impairment, cyanosis of the glans)

• severe degree (necrosis of the glans penis)

1.6 Clinical presentation of the disease or condition

1.6.1 Testicular torsion

Typical form. Acute pain with rapidly increasing intensity is the most frequent symptom [1-9, 11-15]. It can be localized not only in the scrotum, but also in the groin and lower abdomen, mimicking acute abdominal pathology, and may develop during sleep, leading to the patient's awakening; it may occur after direct trauma (in 4-8% of cases), after intense physical exertion, or due to a sharp change in temperature (diving into cold water). Therefore, testicular torsion should be ruled out in acute abdomen syndrome and following scrotal trauma. In their medical history, some patients note intermittent acute scrotal pain, unilateral or bilateral, resolving spontaneously. Other symptoms include nausea, vomiting, and abdominal pain. In newborns with testicular torsion, there may be restlessness, but usually the first sign is scrotal edema immediately after birth or during diaper changes in the first days of life.

Upon early examination, tenderness and scrotal edema are detected in 88% and 44% of patients, respectively [5]. Hyperemia and elevated body temperature are usually absent. The testis is drawn up toward the root of the scrotum due to shortening of the spermatic cord [1-9, 11-15]. Unlike epididymo-orchitis, the pain does not decrease upon elevation of the testis (Prehn's sign) [1, 5]. After a few hours, local edema increases and hyperemia appears. The absence of the cremasteric reflex should raise suspicion of spermatic cord torsion. Conversely, a preserved cremasteric reflex allows the exclusion of torsion with almost 100% sensitivity [4, 5, 81].

Thus, the clinical picture of typical testicular torsion is represented by the following symptoms [4]:

• acute onset of pain

• moderate to severe pain in the scrotum or testis

• possible nausea, vomiting, radiation of pain to the groin, thigh, or abdomen

• several hours after the onset of the disease, edema and hyperemia of the corresponding hemiscrotum appear

• the testis is drawn up to the root of the scrotum and positioned horizontally

• the cremasteric reflex on the affected side is absent or reduced, and its elicitation is painful

• negative Prehn's sign

• with pronounced scrotal edema, gait changes are possible

In cases of delayed presentation—caused by adolescent boys' reluctance to seek medical care or initially misdiagnosed—the diagnosis may be established quite late [5]. In these subacute cases, the pain has already disappeared or become insignificant, and scrotal hyperemia and edema increase. On palpation, the testis is enlarged, minimally tender, has a firm or elastic consistency, and the testis and epididymis cannot be differentiated. Ultrasound examination typically reveals areas of varying echogenicity ranging from anechoic to hyperechoic, indicating extensive necrosis. This is confirmed by color Doppler ultrasound, which demonstrates the absence of blood flow [1-9, 80].

Atypical forms of testicular torsion

Intermittent torsion. Patients experience episodes of severe recurrent scrotal pain radiating to the groin, which resolve spontaneously. They report testicular pain upon self-palpation. At the time of the medical examination, clinical symptoms are generally absent [4, 5, 60-61]. A typical sign of bell-clapper deformity is the horizontal lie of the testis when the patient is standing. If this sign is present, it facilitates diagnosis [5].

Torsion of an undescended testis. Torsion of an intra-abdominal testis may clinically present as an acute abdomen syndrome. Torsion of an inguinal undescended testis may mimic an incarcerated inguinal hernia. Therefore, in a patient with abdominal pain and an unpalpable testis, testicular torsion should be considered as a possible diagnosis [4].

Perinatal testicular torsion. This is a rare variant of testicular torsion with an incidence of 6 per 100,000 births. It is defined as torsion occurring before birth or within the first 30 days of life. This is usually extravaginal torsion. An atrophic testis in the scrotum or in an undescended position discovered after birth can be considered the result of prenatal torsion. Typically, a firm, painless scrotal mass without color change is discovered at birth or in the postnatal period. On ultrasound examination, this testis is hyperechoic and shows no signs of perfusion, which corresponds to the imaging picture of necrosis [4-7]. In the differential diagnosis of a painless, firm scrotal mass in a neonate, the possibility of meconium periorchitis should be considered. This is a rare benign condition resulting from healed intrauterine bowel perforation [5].

1.6.2 Hydatid torsion

The most frequent symptoms of appendix testis torsion are moderate scrotal tenderness during walking, physical activity, or upon touch [1-9, 79, 45, 93]. During bathing, a slightly edematous and reddened scrotum may draw attention [5]. A slow development of symptoms at a younger age (usually under 10 years) is typical, which helps differentiate this condition from testicular torsion [1-9, 11, 15]. 2–3 days after the onset of the disease, edema and hyperemia of the hemiscrotum may appear, which is a sign of secondary inflammatory changes [1]. The head of the epididymis is usually enlarged, leading to a misdiagnosis of epididymitis. In almost 20% of patients, the enlarged appendix with signs of hemorrhagic necrosis is visible through the skin (blue dot sign). An equivalent term used in domestic literature is the "blue spot" sign, introduced by Dressner in 1973 as the most pathognomonic sign of appendix pathology. Synonyms include the black or "dark dot" sign. Its frequency in practice varies somewhat according to various authors, but overall accounts for about a quarter of all clinical cases [93]. According to EAU data, the "blue dot" sign is identified in only 10–23% of patients with appendix testis torsion [5]. A rounded, tender mass can also be palpated on the upper pole of the testis. After locating the point of maximal tenderness and reassuring the boy, the unchanged testis itself can be palpated. The cremasteric reflex is active [5]. Appendix testis torsion may be preceded by scrotal trauma. Based on the clinical manifestations, it is advisable to categorize the pathology by its clinical course, distinguishing [1, 4, 121] an uncomplicated course and a complicated course of the disease.

The uncomplicated course is characterized by moderate pain syndrome in the region of the epididymal head and/or the upper pole of the testis, with the appendix visualized through the skin as the "blue dot" sign.

The complicated course is accompanied by secondary inflammatory changes in the epididymis and scrotum and is characterized by more pronounced pain syndrome, observed also at rest, diffuse hyperemia and edema of half of the scrotum, in which informative palpation becomes difficult [1, 4, 121].

1.6.3 Inflammatory diseases of the scrotum and penis

Epididymitis. There is a gradually increasing pain, swelling, and redness of the scrotum combined with general signs of inflammation, such as high body temperature and weakness [1-11, 14-15, 54, 91-97]. Initially, inflammatory changes predominate in some part of the epididymis or in the epididymis as a whole; as the disease develops, the testis and epididymis merge into a single edematous, dense, and very painful conglomerate. The cremasteric reflex is preserved. At an early age, a more rapid development of clinical symptoms is noted. In the first hours of the disease, general symptoms predominate – "unmotivated" anxiety, refusal to eat, less often – vomiting, lethargy, malaise, accompanied by a temperature rise to 38–38.5°C. Local symptoms are pronounced within the first 12–24 hours.

Examination of the local status in young children is in some cases difficult due to the child's negativism and difficulty in contacting them. The appearance of pronounced edema of the soft tissues of the scrotum and tunicae by the end of the first to the beginning of the second day of the disease complicates the palpation examination and does not allow differentiating the testis and epididymis; the absence of scrotal rugosity is more common. This symptom is present to a greater or lesser extent in all patients, regardless of the duration of the disease. In some cases, predominantly with a disease duration of more than 4 days, edema and hyperemia spread from the scrotum to the inguinal region and the root of the penis [4, 5, 54, 91, 94, 96]. Upon palpation, the epididymis is enlarged and painful, predominantly in the area of the head; palpation of the epididymis can be informative only in the first 1 to 2 days from the onset of the disease, and thereafter becomes impossible due to edema of the testicular tunicae. A concomitant enlargement of the testis and tenderness upon palpation may be noted.

Reactive hydrocele when the inflammatory process is localized in the head of the epididymis (usually non-tension) is detected as early as 12 hours from the onset of the disease, while when the tail of the epididymis is affected – at later dates (2nd–3rd day) [4].

Orchitis. In its manifestations, orchitis is very similar to epididymitis. The main symptoms are: gradually increasing pain in the testis, febrile fever, headache, and malaise. Upon examination, an enlarged testis, painful and inflamed scrotum are usually found. The cremasteric reflex is preserved. In the majority of pediatric patients, mumps symptoms precede orchitis [5, 89].

Allergic scrotal edema. The disease is characterized by a sudden onset and bilateral involvement with the development of edema and hyperemia of the scrotum [4, 5, 19-22]. The nature of the lesion is symmetrical, but predominance on one side or the other is possible. The severity of hyperemia varies from moderate to purplish with petechial hemorrhages. Pain is usually mild, associated with tension of the scrotal integuments and hyperesthesia, or absent. The severity of edema in some cases prevents palpation of the scrotal organs. In rare cases, the spread of edema to the perineum and inguinal region is noted. The general condition of the patient, as a rule, does not suffer. Blood tests show eosinophilia in 40% of cases, which is characteristic of an allergic reaction; in some cases, an increase in immunoglobulin A is noted, but this is not a specific sign. In some cases, there may be moderate leukocytosis [4, 5, 19-22].

Balanoposthitis. The main clinical manifestations of balanoposthitis are edema, hyperemia, tenderness of the glans penis and prepuce; seropurulent discharge from under the prepuce; difficulty in retracting the prepuce; dysuria [53, 148].

1.6.4 Rare acute conditions of the penis

Priapism. The main manifestations of priapism in children are persistent painful erection of the penis not associated with sexual arousal, and the absence of ejaculation [16, 57-59]. With a prolonged course (more than 4 hours), complications may develop: ischemia and necrosis of penile tissues, impaired erectile function, acute kidney injury, deep vein thrombosis.

Paraphimosis. The main manifestations are pain in the penile area, edema and hyperemia of the glans penis with a collar of edematous and hyperemic prepuce around the coronary sulcus, and the impossibility of reducing the glans back under the prepuce. Acute urinary retention is possible with paraphimosis [33]. With prolonged paraphimosis, a disruption of distal venous and lymphatic outflow occurs, and as a result, a decrease in arterial blood inflow to the glans penis. Arterial blood flow may be impaired for several days and weeks, which can lead to severe ischemia and necrosis of the glans penis [40-41].

1.6.5 Injuries of the scrotum and penis

The main symptoms of closed scrotal trauma are pain, edema, and a growing hematoma (from a few hours to a few minutes, depending on the caliber and nature of the damaged vessels). In some cases, with a pronounced hematocele, scrotal "fluctuation" may be determined, which usually disappears within 12–24 hours due to hematoma organization and clot formation. In some cases, the testis is palpated as pressed against the root of the scrotum due to the hematoma. The evaluation of clinical symptoms upon palpation can be sharply hindered both by edema and the presence of a pronounced hematoma that does not allow differentiating the scrotal structures, and by a pronounced pain syndrome [62, 64]. Clinical symptoms in injuries of the scrotal organs are unreliable and cannot in all cases serve as a criterion for the severity of injuries; severe pain syndrome and scrotal edema often lead to overdiagnosis of the extent of injuries, while at the same time, severe trauma with testicular destruction may be accompanied by very moderate pain syndrome [62-65].

Intraparenchymal testicular hematoma is characterized by increasing pain in the absence of significant scrotal edema and hematocele. The intensity of pain is higher than in the rupture of the tunica albuginea, which is due to compression of the parenchyma [4]. A sharp deterioration in the general condition is often noted. The severity of the pain syndrome can be highly variable, up to shock with decreased blood pressure, tachycardia, and altered consciousness.

In open injuries of the scrotum and penis, the nature of the wound is of primary importance. Attention should be paid to the following points:

• Localization. The wound can be located both on the scrotum and affect adjacent areas – the root of the penis, thigh, inguinal region, perineum, contralateral half of the scrotum. The possibility of concomitant injuries should be taken into account.

• The nature of the wound (stab, cut, etc.) gives an idea of the traumatic agent and the mechanism of injury. It is necessary to evaluate the edges of the wound defect – contused with maceration, abrasions, etc.

• The direction of the wound tract makes it possible to suggest the mechanism of injury and assess the possible scope of damage along the path of application of the traumatic agent. The presence of an exit wound (in a stab or gunshot wound) also suggests the trajectory of the wounding agent and the possible nature of the damage.

• Visualized foreign bodies and the nature of wound contamination make it possible to assess the degree of wound infection.

• Bleeding activity. In superficial wounds, the nature of bleeding is usually capillary and tends to spontaneous hemostasis; the wound is covered with a clot. Injury to the testis with massive destruction of its parenchyma in an open wound is more often accompanied by venous bleeding; palpation of the scrotum may reveal an outflow of blood from the scrotal cavity through the wound, which is sometimes regarded as an increase in bleeding. Arterial bleeding may be noted in case of damage to the testicular artery, but such an injury is casuistic in nature [4].

The clinical picture in penile trauma depends on the nature and severity of the injury [33-38, 127]. The main symptoms are

• Pain in the area of injury

• Bleeding (external, internal)

• Penile deformity

• Functional impairment (urinary and erectile dysfunction)

In severe injuries (amputation, degloving, extensive ruptures), shock, blood loss, and acute urinary retention may develop.

Penile tourniquet syndrome is a condition occurring in boys under five years of age when long hairs, most commonly maternal, accidentally wrap around the penis, causing strangulation. The strangulation typically occurs in circumcised children, and the most common site is the coronal sulcus. The child may be restless and crying due to pain and discomfort in the penile area. Edema and skin discoloration, such as local hyperemia or cyanosis, may indicate the presence of a constricting hair tourniquet and signify impaired blood circulation in the strangulated area. Prolonged strangulation may lead to loss of sensation in the glans penis. Delayed diagnosis and treatment can result in urethrocutaneous fistulas, damage to the corpora cavernosa, urethral stricture, and in rare cases, partial or complete self-amputation of the penis [149-150].

Tear of the prepuce frenulum is one of the most frequent traumatic injuries in children. This type of injury most commonly occurs during forceful retraction of the foreskin or during sexual intercourse. Patients with a tear of the penile frenulum typically present with complaints of bleeding, pain, and edema in the frenulum area [143].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of acute conditions and injuries of the scrotum and male genital organs is based on interview data (complaints and medical history), physical examination findings, and laboratory and instrumental test results. The differential diagnosis is most commonly made between testicular torsion, torsion of the appendix testis, acute orchiepididymitis, and traumatic rupture of the testicle. Despite the high prevalence of these conditions in the population, the rate of misdiagnosis remains high. Errors include both overdiagnosis, driven by the fear of "missing" testicular torsion with its resulting reproductive and social consequences, and underdiagnosis. The latter occurs predominantly among specialists in adult healthcare settings who rarely encounter this pathology. Most frequently, patients with acute scrotum syndrome are managed with a diagnosis of acute epididymitis, and clinical improvement during treatment further convinces the attending physician of its correctness. Among general practitioners, the rate of misdiagnosis reaches 45%. Recently, the rate of errors has decreased somewhat, primarily due to the widespread implementation of ultrasonography [4, 5].

Diagnostic criteria:

1. Anamnestic data indicating the nature and time of onset of symptoms (see section 1.6).

2. Physical examination data (see section 1.6).

3. Laboratory examination data.

4. Instrumental examination data.

Comments: the patient's stay in the emergency department should not exceed 2 hours. Once a diagnosis of testicular torsion is established in the emergency department, manual detorsion of the testicle must be performed in the absence of contraindications. If ineffective, the child should be immediately transferred to the operating room for emergency surgical treatment. If manual detorsion is successful, the child may be hospitalized in the surgical department and undergo surgery on an expedited elective basis.

Comments: the initial examination of the patient in the surgical department by a pediatric surgeon must be performed no later than 2 hours after hospitalization, with a note in the medical record. Based on the examination results and taking into account the completed laboratory and instrumental workup, a diagnosis must be established and indications for expedited surgical treatment determined, or conservative treatment prescribed (for orchiepididymitis, uncomplicated torsion of the appendix testis, etc.).

2.1 Complaints and Anamnesis

Comments: when interviewing the patient, it is necessary to establish the nature of onset and duration of the disease, the fact and mechanism of injury, the nature and localization of pain, the presence of nausea and vomiting, decreased appetite, elevated body temperature, dysmorphic (dysuric) symptoms, preceding physical activity, previous similar episodes of pain, and prior surgical interventions on the genitalia. The duration of symptoms prior to seeking medical care in testicular torsion is generally shorter than in torsion of the appendix testis and acute epididymitis. Within the first 12 hours, medical care is sought by 69% of patients with testicular torsion, 62% with torsion of the appendix testis, and 31% with orchiepididymitis [5]. Prepubertal boys more frequently exhibit atypical and delayed symptoms, leading to delayed diagnosis and treatment, as well as a higher rate of orchiectomy compared to postpubertal individuals [5]. In torsion of the appendix testis, a triggering factor may be a prior minor scrotal trauma.

2.2 Physical Examination

Comment: the general condition of patients with acute conditions and isolated trauma of the scrotum and male genital organs is usually of moderate severity. In testicular torsion, the child suffers due to severe pain. In severe injuries of the scrotum and male genital organs (amputation, degloving, extensive lacerations), blood loss and shock development are possible.

Comment: inspection of the external genitalia reveals the correct development of their structures, skin color, presence of edema and/or soft tissue infiltration, skin lesions, localization of pathological changes, presence of penile erection, as well as the presence of discharge from the urethra and preputial sac.

In infectious etiologies of the disease and due to the development of aseptic inflammation from impaired blood circulation in the testicle or appendix testis, edema and hyperemia of the affected half of the scrotum are present. In allergic etiologies of acute scrotum syndrome, the changes are bilateral. In torsion of the appendix testis, in almost 20% of patients, the enlarged appendix with signs of hemorrhagic necrosis is visible through the skin (blue dot sign).

In testicular torsion, attention is drawn to the enlargement and superior retraction of the affected half of the scrotum.

In trauma, there are typically external injuries in the form of bruising, hematomas, or wounds. If a wound is present in the external genitalia area during the initial examination, any manipulation should be avoided, and the nature, size, localization, presence, and intensity of bleeding should be assessed. Following the examination, an aseptic dressing is applied to the wound, and further manipulations are performed in the operating room under general anesthesia [4].

In paraphimosis, attention is paid to the color of the glans penis.

Visual inspection of the external genitalia must also be performed in all children with acute abdominal syndrome, as scrotal pathology can be a cause of abdominal pain.

Comments: palpation should be performed slowly, starting with outwardly normal areas of the scrotum, using warm hands. Palpation must determine the position of the testes, the presence and severity of tenderness, consistency and size of the testes; presence of thickening and tenderness of the spermatic cord, and presence of the cremasteric reflex on the affected and contralateral sides. Palpation of the penis should determine the mobility and extensibility of the prepuce, assess skin sensitivity in priapism, and evaluate the possibility of reducing the glans beneath the foreskin in paraphimosis.

In testicular appendage torsion, a rounded, painful mass can be palpated at the upper pole of the testis. The epididymal head is usually enlarged, which may lead to a misdiagnosis of epididymitis. After locating the point of maximum tenderness at the site of the torsed appendage, the unchanged testis itself can be palpated [5]. The cremasteric reflex is preserved.

2.3 Laboratory Diagnostics

Comments: an elevated leukocyte count with a left shift is a sign of an inflammatory process in both infectious pathology and the development of aseptic inflammation. In acute scrotum syndrome and scrotal trauma, the leukocyte count may be slightly elevated. In testicular torsion at the onset of the disease, an increase in the leukocyte count is observed, presumably associated with a stress autonomic reaction to acute pain caused by testicular ischemia. Other parameters of the complete blood count are generally within age-related norms.

Comments: the urinalysis result can be useful in differential diagnosis with epididymitis [89]. However, in epididymitis, only a small proportion of patients have a positive urine bacterial culture result [4, 5, 98]. It should be remembered that the absence of changes in the urinalysis does not rule out epididymitis. Similarly, changes in the urinalysis do not rule out testicular torsion [5]. In prepubertal boys with acute epididymitis, urogenital anomalies are detected in 25–27.6% of cases. The advisability of a full urological workup for all children with acute epididymitis remains controversial [5].

2.4 Instrumental Diagnostics

Comments: Doppler ultrasound is an informative method in the examination of children with acute scrotal conditions, with a sensitivity of 63.6–100%, specificity of 97–100%, positive predictive value of 100%, and negative predictive value of 97.5% [70-76, 83, 94-106]. Color Doppler ultrasound helps reduce the frequency of surgical scrotal exploration, but ultrasound results are subjective, and its performance in prepubertal children presents a number of challenges [73, 77].

During scrotal ultrasound, the condition of both testes is assessed. Ultrasound must evaluate the thickness and stratification of the scrotal wall, the position of the testes in the scrotum and their shape (oval or round); contour integrity, the presence and nature of fluid (exudate, blood) in the tunica vaginalis; echogenicity of the testicular and epididymal parenchyma, linear dimensions of the testis and epididymal head; position of the epididymis relative to the testis; additional formations: appendages, calcifications; the spermatic cord in the inguinal and scrotal parts (linear nature of structures); blood flow in the testis and spermatic cord.

In testicular torsion, the testis is located at the root of the scrotum or horizontally, has a rounded shape, is enlarged in volume along with the epididymis, echogenicity is reduced and heterogeneous, blood flow is reduced or absent; at the level of the superficial inguinal ring or the upper third of the scrotum, the "whirlpool" or "snail" sign is detected—a spiral course of the spermatic cord; fluid is detected in the tunica vaginalis. In the early stages of torsion (incomplete or intermittent), arterial blood flow may be detected in the testis, which complicates diagnosis. Preservation of arterial blood flow does not exclude the diagnosis of testicular torsion. In a multicenter study including 208 boys with testicular torsion, testicular blood supply was normal or increased in 24% of cases [74]. It is always necessary to make a comparison with the healthy side [5]. A positive "wheel spoke" sign (presence of spiral vascular deformation) has a combined sensitivity and specificity of 0.73 (95% CI 0.65–0.79) and 0.99 (95% CI 0.92–0.99), respectively, and can be considered a reliable sign of testicular torsion [5]. In newborns, it has low diagnostic accuracy [77].

In intermittent testicular torsion, scrotal ultrasound reveals post-ischemic hyperperfusion of the epididymis in the form of increased blood flow and a reactive hydrocele, which are often interpreted as epididymitis. With a clinically unequivocal diagnosis of testicular torsion, waiting for an ultrasound should not delay the time to detorsion [77, 79].

To detect an altered appendage, it is advisable to perform multi-position scanning in the area of the epididymal head (the typical localization for an appendage) [1]. Pathological changes in the early stages of appendage torsion or in an uncomplicated course against the background of the epididymal head are masked as epididymitis. Ultrasound allows differentiation between complicated and uncomplicated variants of appendage torsion. In the absence of clinical signs of a complicated disease course (scrotal edema and hyperemia), the detection of echographic symptoms of secondary epididymitis and/or hydrocele, and thickening/stratification of the scrotum is a criterion for the instrumental diagnosis of a complicated course of appendage torsion.

Open scrotal trauma is not a contraindication for ultrasound. To prevent gel from entering the wound, the ultrasound transducer with gel can be immersed in a sterile glove.

Comments: Ultrasound to monitor the disease course and exclude postoperative complications is performed during days 3–5 of inpatient treatment.

2.5 Other Procedures

Comments: dynamic contrast-enhanced subtraction MRI of the scrotum, like scintigraphy, has sensitivity and specificity indicators comparable to ultrasound [5, 81-82]. These studies are necessary in cases where, based on physical examination and color Doppler ultrasound, the diagnosis is unlikely, but medical history does not allow testicular torsion to be ruled out. MRI can also be performed in scrotal trauma and suspected testicular malignancy.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Testicular torsion

3.1.1 Conservative treatment

Comments: when possible, manual detorsion is performed under color Doppler ultrasound guidance, assessing the presence of signs of torsion and testicular blood flow before and after manual detorsion. Manual detorsion is performed within 6 hours of disease onset in all cases, and in the absence of scrotal edema—within up to 24 hours (with a high probability of incomplete torsion).

Manual detorsion is performed in the direction opposite to the median raphe of the scrotum, lifting the testis and pushing it outward ("opening a book") in several steps. If pain increases or resistance to rotation occurs, detorsion is performed in the opposite direction. This maneuver is repeated 2–4 times until a sense of relief appears, the testis descends lower, and the pain goes away almost immediately or shortly thereafter. Doppler ultrasound shows the appearance and subsequent intensification of blood flow in the testis, the disappearance of the spiral deformation of the spermatic cord, and a linear course of the structures of the scrotal part of the spermatic cord. Clinical indicators of effective manual detorsion include:

• relief of pain syndrome,

• return of the testis to the correct anatomical position,

• pain-free downward traction of the testis,

• hyperperfusion according to color Doppler ultrasound [17, 99-107].

According to EAU guidelines, manual detorsion of the testis is performed without anesthesia and should be attempted in all possible cases, as it improves testicular salvage rates [5, 101]. Following successful detorsion, bilateral orchiopexy is indicated. This surgery is performed not electively, but immediately after detorsion, because residual torsion may persist following manual detorsion. For instance, a published study reported that 17 out of 53 patients were found to have residual torsion during exploration, including 11 patients who experienced no pain after manual detorsion [102, 104]. External cooling is recommended to reduce ischemia-reperfusion injury and preserve the viability of the affected and contralateral testis. Pharmacotherapy aimed at reducing testicular injury remains experimental [108-111].

3.1.2 Surgical treatment

Comment: a diagnosis of testicular torsion is an indication for surgical treatment. If manual detorsion is ineffective, surgical treatment must be performed immediately. The inability to perform an ultrasound should not delay surgery. If manual detorsion is effective, surgical treatment should be performed as soon as possible, as required for the child's admission to the surgical department and depending on operating room availability. In cases of intermittent testicular torsion outside of the acute episode and testicular torsion with spontaneous detorsion, the child should be hospitalized, and surgical treatment can be performed on an urgent or delayed basis.

It is advisable to use a longitudinal midline (median raphe) scrotal incision according to Wesling to access both testes for bilateral fixation. In cases of pronounced inflammatory changes extending across the entire scrotum, the incision is made on the affected side. Upon delivering the testis on the affected side, attention is paid to edema of the testicular tunics, the presence and nature of effusion in the serous cavity, and macroscopic changes in the testis. Detorsion is performed with assessment of the degree of torsion (number of turns / degrees), evaluating the appearance of the testis before and after detorsion, and the ligamentous apparatus of the testis. Criteria for testicular viability include: pulsation of the spermatic cord vessels and change in testicular color following detorsion [4-9, 99-107].

If testicular necrosis is absent, its fixation is recommended [1, 4, 65, 99-107]. It is most appropriate to fix the testicle at three distant points using 5/0 atraumatic non-absorbable suture material, while maintaining the anatomical position of the testicle. Whenever possible, it is recommended to place sutures extra-capsularly — perform insertion and extraction outside the parietal layer of the tunica vaginalis testis, in which case the knot will be located outside the serous cavity; suture the testicle by a 2–3 mm area of the tunica albuginea with a needle insertion depth into the testicular parenchyma of no more than 2 mm to minimize trauma. According to EAU data [5], no consensus has been reached regarding the preferred type of fixation and suture material [117-118].

According to EAU recommendations, it is advisable to simultaneously fix the contralateral testicle [5]. Most modern researchers also recommend performing orchiopexy on the contralateral side simultaneously in all cases, with the exception of marked hyperemia and edema of the entire scrotum [4, 5, 17, 99-100, 106, 118]. Intraoperatively, a closed test for testicular hypermobility is performed (manually through the scrotal skin, the testicle can be twisted by 1.5 turns or more). Through the previously made skin incision along the scrotal raphe, the contralateral testicle is delivered into the wound, and an open hypermobility test is performed (the testicle can be effortlessly twisted by 1.5 turns or more). Intraoperatively, an anomaly of testicular fixation — the "bell-clapper" deformity — is typically revealed. Fixation is performed according to the technique described above.

Meticulous hemostasis at all stages of the surgery ensures a smooth postoperative course; in case of doubt, drainage is indicated to prevent postoperative scrotal hematoma.

The benefit of surgical exploration must be weighed against the child's general condition in cases of perinatal testicular torsion. Immediate exploration right after birth is not considered necessary, as such a testicle is invariably necrotic. However, there is a 5% risk of asynchronous contralateral torsion between 8 hours and 6 weeks after the initial torsion, which necessitates early orchiectomy and fixation of the opposite testicle [5]. Detection of testicular torsion in the neonatal period requires bilateral scrotal exploration with orchiopexy of the contralateral testicle [5, 17, 113-115]. In cases of acute postnatal torsion with an edematous and erythematous scrotum, manifested by infant distress or discovered during diaper changes, emergency surgical treatment is indicated [4, 5].

Comments: when testicular necrosis is confirmed, orchifuniculectomy is indicated, which is performed with the maximum possible isolation of the spermatic cord elements up to the level of the superficial inguinal ring.

Comments: testicular torsion is occasionally associated with a testicular tumor, therefore histological examination of the removed testis is always mandatory [5, 7].

Comments: if the testis is viable, it is necessary to perform its simultaneous scrotal descent and orchiopexy (testicular descent surgery).

3.2 Torsion of the testicular appendage

3.2.1 Conservative Treatment

Comments: NSAIDs (ibuprofen**, paracetamol**) are used for conservative treatment for anti-inflammatory purposes in age-appropriate dosages for 3–5 days. Prescribing half of the daily dose divided into 2–3 intakes is effective to reduce the risk of side effects (personal observations). Clinical and ultrasound monitoring must be carried out during therapy. If there is positive dynamics, conservative treatment is continued for up to 5–7 days [1, 4]. If clinical symptoms persist or worsen and ultrasound signs of inflammation appear (2–3 days), delayed surgical treatment—removal of the hydatid—is indicated [1, 4, 119].

3.2.2 Surgical treatment

Comments: surgical treatment is performed on an urgent basis after supplementary examination (scrotal ultrasound) [1, 4, 119]. Surgical treatment in the early stages of the disease for uncomplicated cases is also advisable if ultrasound reveals a large hydatid (6 mm or more), when there is a high probability of prolonged persistence of symptoms or the development of secondary inflammation during therapy. The surgery is performed under general anesthesia via a transverse skin incision of the scrotum on the affected side at the border of the upper and middle thirds, 1.5–2 cm long. The state of the testicular tunics and the nature and amount of effusion upon opening the serous cavity are assessed. With the testis fixed manually by the assistant and an incision made over the projection of the hydatid, complete delivery of the hydatid into the wound and hydatidectomy by electrosurgery of the stalk are possible. Given the high diagnostic value of ultrasound, exploration of the testis with delivery into the wound through a larger incision is traumatic and impractical, as it is associated with trauma during repositioning of the testis. Removal of an accompanying unchanged epididymal hydatid is possible if necessary, but is not strictly mandatory.

3.3 Acute scrotal and penile conditions

3.3.1 Conservative treatment

Comments: as a rule, conservative treatment involves systemic antibacterial drugs (first-line drugs: penicillins combined with beta-lactamase inhibitors (ATC: Combinations of penicillins, including beta-lactamase inhibitors (J01CR)) or second-generation cephalosporins (J01CD) combined with metronidazole (J01XD01)) [1-10]. According to EAU guidelines, antibiotic therapy is in most cases not indicated if bacteria are not detected in urinalysis and urine culture [5, 120-121]. NSAIDs are indicated for analgesic and anti-inflammatory purposes (Ibuprofen**, Paracetamol**), along with physical activity minimization (semi-bed rest) [1-10, 120-121]. Epididymitis usually resolves spontaneously and heals without residual effects.

For balanoposthitis, sanitation of the preputial sac—local application of antiseptics—is recommended. If local treatment is ineffective or the general condition is impaired, systemic antibacterial therapy is prescribed.

Comments: pain management, adequate fluid intake, warm baths, physical activity, cleansing enema. In high-flow priapism, local cold application is prescribed [58]. In secondary priapism, treatment of the underlying disease is paramount.

Comments: reduction of the foreskin is performed under local anesthesia (topical, infiltration, regional) or general anesthesia in young children. Paraphimosis reduction is performed bimanually. First, abundant lubrication of the glans penis and prepuce with a glycerin solution or liquid petrolatum is performed. Then, using the palm and fingers of the dominant hand, gradual forceful compression of the glans penis is applied to reduce venous stasis for 30 seconds. After that, the glans penis is pressed with the thumbs of both hands, while the other fingers pull the foreskin ring forward, inverting the prepuce back into place [39].

3.3.2 Surgical treatment

Comments: plastic surgery on the prepuce is advisable in xerotic obliterans balanitis.

Comments: bacterial epididymitis may be complicated by testicular abscess or necrosis, which require surgical exploration [4, 5, 96]. When clinical and ultrasonographic signs of abscess formation are present, sanitation and drainage of the abscess are performed alongside antibacterial therapy [4, 96].

Comments: emergency puncture of the corpora cavernosa through the glans penis with blood aspiration is performed. The volume of blood removed during aspiration should be limited to 7.5 ml/kg (10% of the blood volume in children over 1 year of age) due to the risk of inducing hypovolemia or shock [58]. Vasoconstrictors (etilefrine, phenylephrine, adrenaline, metaraminol) are injected into the corpora cavernosa [58]. Elective procedures include embolization and shunting surgery.

Comments: an emergency longitudinal incision 1-2 cm long is made on the narrowed part of the prepuce on the dorsal surface at 12 o'clock, followed by its closure in the transverse direction. Circumcision is indicated on a delayed or elective basis.

3.4 Injuries of the scrotum and penis

3.4.1 Conservative treatment

Comments: surgical treatment of scrotal hematomas without injury to the testis and/or epididymis is impractical, since posttraumatic scrotal hematomas imbibe the testicular tunics, their drainage is impossible due to the absence of a hematoma cavity, and additional trauma worsens the course of the process [1, 4, 5]. Conservative treatment is recommended for blunt penile trauma in children, when injury to the tunica albuginea generally does not occur. Typically, a subcutaneous hematoma is observed after trauma without rupture of the tunica albuginea and damage to the corpora cavernosa [5]. In such cases, the use of nonsteroidal anti-inflammatory drugs and local treatment are recommended.

Comments: after successful manual reduction, delayed orchidopexy is performed.

Comments: conservative treatment includes stopping the bleeding by applying local pressure to the rupture area.

3.4.2 Surgical treatment

Comments: an incision is made on the affected side sufficient to deliver the testis into the wound for a thorough exploration. Economic excision of nonviable parenchyma herniating through the rupture of the tunica albuginea and continuous suturing of the tunica albuginea with a 4/0 absorbable suture on an atraumatic needle, along with drainage of the serous cavity, are performed.

Comments: if initial manual reduction fails, emergency orchidopexy is indicated. If manual reduction of the testis is successful, orchidopexy is performed on a delayed basis.

Comments: in severe penetrating injuries, surgical exploration and removal of crushed and necrotic tissue are indicated (EAU). Treatment principles include the removal of devitalized tissue, maximal preservation of remaining areas, hemostasis, urinary diversion as indicated, and foreign body removal [125]. After thorough wound irrigation, the defect in the tunica albuginea must be closed. In case of a significant defect, immediate or delayed patch plasty (using an autologous greater saphenous vein or xenograft) can be performed. Postoperatively, pain management and antibacterial therapy are prescribed.

Comments: in case of complete avulsion of the spermatic cord, reapproximation without vasovasostomy is recommended if technically feasible [123]. After rehabilitation, secondary microsurgical vasovasostomy can be performed, although only a few cases are described in the literature [123]. In case of extensive damage to the tunica albuginea, mobilization of a free flap of the tunica vaginalis testis is performed. If the patient is in an unstable condition or reconstruction is impossible, orchiectomy is indicated. Following penetrating scrotal injuries, prophylactic antibiotics are recommended, although there is no data on their efficacy in the literature. In case of extensive scrotal skin damage, closure is performed. Thanks to skin elasticity, primary closure is possible in most cases, even with minimal fixation of the damaged skin to the scrotum [124]. Wound care and wide excision of damaged tissue are crucial for good healing. Significant loss of genital tissue, such as from improvised explosive devices, generally requires complex and staged reconstructive interventions [124]. Over the past few decades, testicular salvage rates in combat trauma have increased due to improved quality of care (up to 67.6%) [125].

Comments: for suturing the tunica albuginea, a longitudinal incision located in the fracture zone or a ventral longitudinal incision is used [130].

Comments: if bleeding persists, placement of absorbable sutures may be required. For recurrent tears, elective frenulotomy or frenuloplasty is recommended.

Comments: early management includes intensive care and preparation for surgical penile reimplantation if the amputated part is preserved [5]. It is advisable to perform reimplantation in all patients within the first 24 hours [133]. The amputated penis should be washed in sterile saline, covered with saline-moistened gauze, placed in a sterile bag, and immersed in ice water. A pressure dressing or tourniquet should be applied around the penile stump to prevent major blood loss [5]. A suprapubic cystostomy should be placed for urinary diversion. Using an operating microscope, the corpora cavernosa and urethra can be approximated and sutured first, followed by anastomosis of the dorsal arteries of the penis, dorsal vein, and dorsal nerve [134]. Penile reimplantation is recommended in all feasible cases [135].

3.5 Postoperative management

Comments: following surgical treatment for testicular torsion in the postoperative period, NSAIDs are prescribed in age-appropriate dosages (ibuprofen**, paracetamol**) [5, 10, 99-100, 106].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments: in the postoperative period, physical therapy is indicated to improve blood circulation, reduce edema and inflammation, and accelerate tissue regeneration. The choice of physical therapy depends on the type and scope of the surgical intervention and the course of the postoperative period. To improve reparative processes and prevent postoperative infectious complications, microwave (DMV) therapy, magnetotherapy, and laser therapy are used. Medical exercise therapy is prescribed to restore the patient's motor activity. Medical rehabilitation also includes psychological rehabilitation to correct psycho-emotional disorders.

Sanatorium-resort treatment is indicated during the rehabilitation period after surgical treatment to consolidate the achieved results. It includes the use of natural therapeutic factors (climatotherapy, balneotherapy, pelotherapy) combined with physiotherapeutic methods.

Comments: testicular prosthetics is a mandatory component of patient rehabilitation. It is most appropriately performed 6-9 months after testicular loss in patients older than 15 years once mature Tanner stage is reached. Modern synthetic testicular implants should be preferred. The intervention should be performed via an inguinal approach with removal of the preserved spermatic cord tissues and closure of the scrotal entrance over the implant.

5. Prevention and Dispensary Observation

5.1 Prevention

Prevention of traumatic injuries to the scrotal organs and penis in children includes educational and awareness work among parents and children regarding safe behavior rules aimed at preventing injuries [4]. Prevention of inflammatory diseases of the penis (balanoposthitis) and paraphimosis consists of observing personal hygiene rules, sanitation of chronic infection foci, eliminating contact with irritants, and timely treatment of phimosis [136]. The main measure for preventing secondary priapism is the treatment of the underlying condition.

5.2 Dispensary monitoring

Comments: if the testicle is salvaged, evaluation by a pediatric urologist, scrotal ultrasound, and testicular vessel duplex ultrasonography are recommended at 1, 3, 6, and 12 months; following orchiectomy, evaluation by a pediatric urologist at 1 month and 1 year [138-140].

Comments: all children who have suffered penile trauma are subject to follow-up monitoring until reaching adulthood. Regular examinations by a pediatric urologist-andrologist and penile ultrasound (every 3–6 months during the first year, then once a year).

6. Organization of Medical Care

Indications for hospitalization in a medical organization:

If acute conditions and trauma of the scrotal organs and penis are suspected, emergency hospitalization in a pediatric surgical hospital is indicated [2].

Indications for patient discharge from a medical organization:

• General condition of the child: satisfactory.

• No complaints.

• No abnormalities on laboratory testing.

• No complications according to ultrasound data (ultrasound examination of the scrotal organs; ultrasound examination of the penis).

Recommended hospitalization duration: 3–10 days.

7. Additional Information

Not applicable.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Grigoryeva Marina Vitalievna, PhD in Medicine, Leading Researcher, Research Institute of Emergency Pediatric Surgery and Trauma - Dr. Roshal Clinic, Moscow Department of Health, Member of the Russian Association of Pediatric Surgeons, Moscow, Russia. No conflict of interest.

Bryantsev Alexander Vladimirovich, PhD in Medicine, Honored Doctor of the Russian Federation, Director of the Research Institute of Emergency Pediatric Surgery and Trauma - Dr. Roshal Clinic, Moscow Department of Health, Member of the Russian Association of Pediatric Surgeons, Moscow, Russia. No conflict of interest.

Gasanova Ella Nizamievna, PhD in Medicine, Researcher, Research Institute of Emergency Pediatric Surgery and Trauma - Dr. Roshal Clinic, Moscow Department of Health, Member of the Russian Association of Pediatric Surgeons, Moscow, Russia. No conflict of interest.

Karaseva Olga Vitalievna, MD, PhD, Deputy Director for Research, Head of the Department of Polytrauma, Anesthesiology and Intensive Care, Research Institute of Emergency Pediatric Surgery and Trauma - Dr. Roshal Clinic, Moscow Department of Health, Chief freelance pediatric specialist for polytrauma of the Moscow Department of Health, Member of the Russian Association of Pediatric Surgeons, Moscow, Russia. No conflict of interest.

Sarukhanyan Oganes Oganesovich, MD, PhD, Head of the Department of Pediatric Surgery, Research Institute of Emergency Pediatric Surgery and Trauma - Dr. Roshal Clinic, Moscow Department of Health, Member of the Russian Association of Pediatric Surgeons, Moscow, Russia. No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Pediatric urologists-andrologists

2. Pediatric surgeons

3. Pediatricians

4. Nephrologists 

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2.  Scale for assessing levels of evidence (LoE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for grading grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

None provided.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Testicular torsion is an emergency condition in which the blood supply to the testis is disrupted and its structural integrity is damaged. Delayed medical attention can lead to testicular necrosis.

The condition is most common between the ages of 12 and 18 years, so it is necessary not only for parents to be aware of it, but also to inform adolescents. It is important to explain that fear and embarrassment regarding reporting symptoms in the genital area can lead to serious consequences.

The main symptoms of the condition are:

- acute, severe pain in the scrotum, which may radiate to the abdomen or groin and intensifies with movement,

- nausea and vomiting at the peak of the pain,

- redness and swelling of the scrotum appearing a few hours after symptom onset.

If these symptoms occur, you should seek medical attention immediately. The diagnosis can be established during the patient interview and physical examination. The physician may also order an ultrasound examination as an additional diagnostic method.

If the disease onset is within a few hours, the doctor may perform a manual detorsion procedure by rotating the testis. When successful, testicular blood flow is restored and the pain resolves.

Testicular torsion is an indication for surgical treatment. During the surgery, the doctor corrects the torsion, and if the organ is deemed viable, fixation is performed to prevent disease recurrence. In cases of severe ischemia and necrosis, the organ is removed.

Predisposing factors for testicular torsion are most commonly congenital structural anomalies of its suspensory apparatus; therefore, if torsion occurs in one hemiscrotum, there is a probability of it occurring on the contralateral side as well. For prevention, simultaneous fixation of the contralateral testis is performed.

Following surgery and discharge from the hospital, outpatient follow-up by a pediatric urologist-andrologist is indicated.

In the event of testicular loss, 6 to 9 months after the orchiectomy, if indicated, testicular prosthesis implantation may be performed, where an implant is placed in place of the removed organ. This surgery allows for the restoration of the appearance of the scrotum.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

None provided.